I feel for the Nurses wanting to practice independently however but I don't know what they want to practice, it certainly is not medicine! I worked hand to hand with several advanced NP's and found their knowledge and judgement capacity definitely flawed from mine as a practicing FP. I feel sorry for them but facts are facts. They can't possibly have the knowledge and capacity to understand lab values, patient symptoms and findings as a physician because they do not get medical school training which is far superior to their short time learning to manage patients as physicians do. Judgement for management of the one more complicated case is very poor but the physician seeing the exact case will pick up signs and symptoms and come to a very different diagnosis that may be critical for that one patient. Granted they could likely diagnose the run of the mill cold or flue but should have physician input and judgement in all cases. Nurses regardless of their status are still nurses. Make all nurses go through the extensive training of physicians if they want that status. NY people must tell their politicians to leave nurses where they are as helpers for physicians. Otherwise take the risk of being that one patient the nurse would miss. I speak from experience! Believe me, you as a patient, a bit more complicated than usual run a serious risk of clinical inexperience missing your diagnosis. Nurses just don't have the knowledge and experience despite their fighting for status they don't deserve! Lawmakers everywhere keep physicians in charge of all helpers! Please!!!.

Disgusted, MD

03/11/14

I have known some absolutely brilliant nurse practitioners. Many
who taught me much (As have some spectacular nurses) during my
education and after. I would almost rather go to them than some of
the lousy doctors I have seen. I suppose Physicians Assistants are
not good enough either? I have to wonder about what we learn in
medical school. Is it overkill in some areas, is it all so very
useful? How many remember their biochemistry after 10 years, for
example? All the rote memorization of minutiae that is soon
forgotten, superseded by clinical wisdom and practice, along with
the drive to keep up with the current medications and treatment
paradigms. To see the first commenter totally put down all nurses,
including NPs is sad (Of note, he refers to NPs and nurses
interchangeably). In my experience, most offices employ medical
assistants only, some with maybe a nurse supervising (There seems
to have been a mass exodus of nurses from many practices). And
those medical assistants are the ones who ask the important
questions that the physician depends on in order to keep visits as
brief as possible. That scares me much more (But again, I have
known some who aspired to learn far more on their own). I will say
I have a very big problem with medical assistants calling
themselves nurses when speaking to patients. I feel that is very
misleading to patients who think they are working with someone with
a nurse's education..

Julie Donalek RN, PhD, APRN BC

03/11/14

Describing advanced practice nurses as in "revolt" as you title the article combined with Handford Brace's
characterization of nurses as "helpers for physicians" both angers and saddens me. We are now in an era
in which every American is finally entitled to health care. With expanded general need and an aging
population, advanced practice nurses are entirely capable of independently managing the great majority
of those seeking care. If we are to effectively meet these needs, all providers need to work cooperatively
and respectfully..

Atul Jain

03/12/14

Tough situation all around. I have worked with (and under) some amazing mid-levels and have learned from them. They are an integral part of the health care team. For example, as a primary care physician for very complex patients I don't have the time in a 20-minute visit to focus on diabetes care management as much as I'd like to (because I have to deal with their out-of-control BP, recurrent depressive episode, COPD, obesity counseling, etc). That's where the NP I send them to does a phenomenal job. This is only one example out of many.
I feel that the majority of mid levels are clearly capable of managing straightforward disease presentations, providing ongoing care for certain specialty care, and can administer guideline-based preventive health maintenance. I do not, however, feel that these same providers are the appropriate persons to manage complex patients (those with multiple organ system problems or those with severe/complex presentations of certain diseases).
I also am aware of the argument that NPs may be the solution to our primary care gap. However, my understanding is that recent data has observed that most NPs entering the workforce eventually gravitate towards specialty care settings.
In addition, in my experience, I have witnessed that many patients who present with a difficult-to-differentiate illness often undergo the "shotgun" workup, where several unindicated labs and other tests are ordered as part of diagnostic evaluation. The problem is that this is a low value approach to care (counter to the argument that NPs are a lower-cost alternative to physicians), furthermore, this often leads not to a clear diagnosis but to an incidental finding that merits additional costly workup that would never have been done if the diagnostic evaluation had been "chosen wisely" in the first place (a nod towards the ACPs Choosing Wisely campaign).
Thus I feel that mid levels are a vital part of a team-based approach to care. I do feel that for many patients they can practice independently and successfully. I'm not convinced that they are more cost-effective providers. They can help with the primary care gap but far less than has been estimated.
I hate to sound reductive, but why not let the market speak? There are more than enough patients to go around thus physicians should not feel threatened by the independent practice by NPs. This will also allow NPs to take on the risk and responsibilities associated with independent practice- the liability, billing headaches, etc.
In the end patients will go where they can easily access care and they will stay in practices where they feel that their needs are carefully tended to, be it in a physician's exam room or in a nurse practitioner's exam room.
Atul Jain, MD, MS
Assistant Professor of Medicine
The University of Chicago.

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